Acute Gastrointestinal Bleeding

Question 1

state the common causes of acute gastrointestinal haemorrhage?

Answer 1

upper GI

lower GI

Question 2

describe the principles of investigation and treatmentt of acute gastrointestinal haemorrhage

Answer 2

Any haemorrhage
Scoring systems
Specialist bleeding units
Specific situations

Question 3

definition of upper GI bleeding

Answer 3

Bleeding from oesophagus, stomach or duodenum
Proximal to ligament of Trietz

Haematemesis
  Melaena
  Elevated Urea
Digested blood: haem -> urea 
 Associated with dyspepsia, reflux, epigastric pain
 Non-steroidal anti-inflammatory use

Question 4

definition of lower GI bleeding

Answer 4

Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz

Fresh blood/clots
Magenta stools
Normal urea (rarely elevated if proximal small bowel origin)
Typically painless 
More common in advanced age

Question 5

causes of upper GI bleeding

Answer 5

ulcers of oesophagus, stomach and duodenum

-itis

Question 6

are gastric ulcers more common than duodenal ulcers?

Answer 6

no

Question 7

risk factors for peptic ulcers

Answer 7

Helicobacter pylori
produces urease -> ammonia produced
-> buffers gastric acid locally => increased acid production
NSAIDs/Aspirin
prostaglandin production -> reduced mucus and bicarbonate excretion => reduced physical defences

Alcohol excess
Systemic illness – “Stress ulcers”

Question 8

what causes recurrent poor healing duodenal ulcers

Answer 8

zollinger-ellison syndrome

Question 9

risk factors for gastritis and duodenitis?

Answer 9

Tend to bleed in context of impaired coagulation
Medical conditions
Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
Anti-platelets (clopidogrel, ticagrelor)

Question 10

causes of oesophagi’s

Answer 10

Reflux oesophagitis
Hiatus hernia
Alcohol
Bisphosphonates
Systemic illness

Question 11

causes of varices

Answer 11

Secondary to portal hypertension, usually due to liver cirrhosis
Abnormally dilated collateral vessels
Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)

Increases in portal pressure (eg infection/drug use/alcohol use) can precipitate bleeding

Question 12

causes of malignancy

Answer 12

Oesophageal cancer
May have dysphagia /weight loss history
Typically “ooze”

Gastric cancer
Can present as an ulcer
GU needs interval endoscopy for healing

Question 13

what is mallory-weiss tear?

Answer 13

Linear tear at oesophago-gastric junction
Follows period of retching/vomiting
Up to 10% significant requiring endoscopic treatment

Question 14

what is diuelafov?

Answer 14

Submucosal arteriolar vessel eroding through mucosa

Gastric fundus

Question 15

what is Angiodysplasia

Answer 15

Vascular malformation
Occurs anywhere in GI tract
Frequent cause of chronic occult or overt occult bleeding
Associated with chronic conditions including heart valve replacement

Question 16

investigations for upper GI bleeding

Answer 16

Upper GI Endoscopy:
Both diagnostic and therapeutic
Within 24 hours – sooner if unstable (NICE 2012)

Question 17

colonic causes of acute lower GI bleeding

Answer 17

Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis 
Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)

Diagnosis requires flexible sigmoidoscopy or full colonoscopy

Question 18

diverticular disease

Answer 18

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch.

Diverticulosis - presence

Diverticulitis - inflammation

Bleeding occurs in 10-20% during the lifetime
Usually self-limiting - 75%

Risk of further bleeding
10% chance of recurrence at one year
25% at four years

Question 19

haemorrhoids

Answer 19

Enlarged vascular cushions around anal canal
Painful if thrombosed or external
Association with straining/constipation/low fibre diet
Common, rarely serious bleeding

Treatment is elective surgical intervention

Question 20

Acute lower GI haemorrhage: angiodysplasia

Answer 20

Vascular malformation
Degeneration
Friable and bleeds easily
May be association with heart valve abnormalities
Bleeding often precipitated by anticoagulants/antiplatelets
May be multiple including small bowel

Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide

Question 21

ischaemic colitis

Answer 21

Disruption in blood supply to colon
Affects areas according to blood supply, typically descending/sigmoid colon
Presents with crampy abdominal pain and sudden bleeding

Question 22

whos more likely to get ischaemic colitis?

Answer 22

over 60

Question 23

complications of ischaemic colitis?

Answer 23

gangrene and perforation

Question 24

radiation proctitis

Answer 24

Previous history of radiotherapy
Cervical cancer
Prostate cancer
Crescendo PR bleeding over months/years
May be dependent on blood transfusions due to chronic loss

Question 25

treatment of radiation proctitis

Answer 25

APC Sulcrafate enemas Hyperbaric oxygen

Question 26

investigations of acute lower GI bleeding

Answer 26

Lower GI endoscopy: Flexible sigmoidoscopy – if large volume views limited Colonoscopy – requires preparation CT Angiography

Question 27

small bowel cause of acute lower bleeding?

Answer 27

If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin (5%) Meckel’s diverticulum Small bowel angiodysplasia Small bowel tumour/GIST Small bowel ulceration (NSAID associated) Aortoentero fistulation – following AAA repair

Question 28

small bowel investigations

Answer 28

CT angiogram Meckel’s scan (Scintigraphy) Capsule endoscopy Double balloon enteroscopy

Question 29

management of GI bleeding

Answer 29

A. Airway B. Breathing C. Circulation: Wide bored IV access => IV fluids, blood transfusion Urgent blood samples to lab: FBC, U&Es, LFTs, Coagulation, blood group and save/ cross match Blood transfusion if Hb<7g/dl or ongoing active bleeding Consider major haemorrhage protocol Evidence that transfusing Hb>10g/dl has worse outcomes Catheter ?? Tranexamic acid D. Disability E. Exposure

Question 30

risk stratification UGIB: blatchford score pre-endoscopy score

Answer 30

``` Blood urea (mmol/L) Haemoglobin for men (g/L) Haemoglobin for women (g/L) Systolic blood pressure (mm Hg) Other markers Hepatic disease Cardiac failure ```

Question 31

risk stratification UGIB: Low-risk criteria of Glasgow Blatchford Score

Answer 31

urea <6·5 mmol/L haemoglobin >=130 g/L (men) or >=120 g/L (women) systolic blood pressure >=110 mm Hg pulse <100 beats per min absence of melaena, syncope, cardiac failure, or liver disease Scores ≥6 associated with a greater than 50% risk of needing an intervention

Question 32

management of GI bleeding: peptic ulcer

Answer 32

Proton pump inhibitors Endoscopy with endotherapy Angiography with embolization Laparotomy

Question 33

endosxopic therapy options for peptic ulcer

Answer 33

``` Injection Adrenaline 1:10000 Thermal Contact – “gold probe” Mechanical Clip Haemospray ```

Question 34

management of varies

Answer 34

Endotherapy Oesophageal Band ligation Glue injection Gastric Glue injection Rectal glue injection IV Terlipressin Vasoconstrictor of splanchnic blood supply Reduces blood flow to portal vein, reducing portal pressures Mortality reduced 32% to 12% IV Broad spectrum antibiotics Often precipitated by systemic infection Correct coagulopathy